Legal Advice: Employed Physicians Dealing with Negative Patient Reviews

To:       Georgia Academy Members

From:  GAFP Congress of Delegates Speaker, Carl McCurdy, MD

Congress of Delegates Vice Speaker, Samuel Le Church, MD

As a follow up to one of our Congress of Delegates resolutions passed last year, we are providing education on how to deal with negative patient reviews and dealing with an employer.  The Georgia Academy thanks partner Southern Health Lawyers, for the development of this article.  Rich Sanders is an attorney in Atlanta representing family physicians throughout Georgia. He can be reached at (404) 806-5575 or

Limiting the Effect of Negative Patient Reviews on Employed Physicians

In accordance with patient-centered healthcare, patient satisfaction metrics not only affect physician reimbursement levels, but are also a growing component of physician compensation formulas. Further, an employer may use a physician’s low patient satisfaction metrics to initiate adverse actions. Utilization of patient satisfaction metrics raises several concerns. Specifically, patient satisfaction metrics measures are based on patients’ expectations of care as opposed to objective measures of experience. Patient perceptions also may not be correlated with technical quality. Additionally, there may be selection and recall bias in the responses of those patients with very positive or negative experiences that inadvertently skew patient satisfaction metrics. Because patient satisfaction metrics may not accurately quantify a family physician’s skill, technical ability, or clinical outcomes, GAFP requested that we draft the following language that may be incorporated into Academy members’ employment agreements / employee handbooks:

Employer may not take adverse action(s), including reflective penalties, against an Employee that receives negative patient surveys, patient satisfaction benchmarks or online reviews, in the absence of formal procedures comporting within the minimum common law requirements of procedural due process. Employer shall notify an Employee, in writing, of its proposed adverse action(s) within five (5) business days of its decision. Employee notification must include information detailing the proposed adverse action(s), basis for the proposed adverse action(s), and formal procedures available to Employee to appeal the proposed adverse action(s). Formal procedures available to an Employee shall include but are not limited to: (i) review documentation Employer considered prior to proposing the adverse action(s), (ii) request an informal in-person meeting with Employer to appeal and negotiate the matter in good faith, (iii) petition the Employer to correct erroneous information submitted by the Employee or a third-party, and (iv) provide a written explanation, including supporting documentation, to Employer challenging the basis of the proposed adverse action(s). All formal procedures available to an Employee to appeal the proposed adverse action(s) must be received by the Employer within thirty (30) days of the notification.

While this sample language may be modified to fit a particular proposed employment agreement for family physicians, we also recommend that Academy members review their current agreements to determine if similar language is already included. If not, it may be appropriate to look for an opportunity to add it in the future.

Dr. Richardson on Top Docs Radio Show

Dr. Richardson addresses meningitis & shingles in the latest edition of the Medical Association of Georgia’s (MAG) ‘Top Docs Radio’ show

Eddie Richardson Jr., M.D., medical director of the Lake Oconee Urgent and Primary Care Center in Eatonton – and former past President and Board Chair of the Georgia Academy Family Physicians, discusses meningococcal and shingles diseases and vaccines. Click here to listen to the radio show.

The Georgia Healthy Family Alliance Launches New Video Highlighting “Women’s Breast Health” Clarkston Community Grant

The Georgia Healthy Family Alliance is pleased to share a new video highlighting a recent Community Health Grant to the Clarkston Community Health Center. The grant is sponsored by GAFP member, Dr. Patrice Shongo, in support of their Women’s Breast Health Project. Click on the video below to see how your donations to GHFA help Georgians every day in communities across the state.

To view the video, visit


*Production support provided by Jackson Healthcare

Prolonged Services: How Do I Document?

To:       Georgia Academy Members

From:    Speaker Carl McCurdy, MD

Vice Speaker Samuel Le Church, MD – GAFP Congress of Delegates

As a follow up to one of our Congress of Delegates resolutions passed last year, CPT consultant Steve Adams generously is allowing us to reprint an article that he has written focusing on prolonged services.  This article is to educate our members on how to code appropriately on extended patient encounter time and additional services.  The Georgia Academy thanks Steve Adams for sharing this article.  If you would like to contact Steve – here is his website:

Prolonged Service

By Steven A. Adams, MCS, CRC, CPMA, CPC, COC, CPC-I, PCS, FCS, COA

Prolonged Services

The CPT definition of prolonged care varies from that of the Centers for Medicare & Medicaid Services (CMS). Since 2009, CPT recognizes the total duration spent by a physician on a given date, even if the time spent by the physician on that date is not continuous; the time involves both face-to-face time and unit/floor time.  CMS only attributes direct face-to-face time between the physician and the patient toward prolonged care billing. Time spent reviewing charts or discussion of a patient with house medical staff, waiting for test results, waiting for changes in the patient’s condition, waiting for end of a therapy session, or waiting for use of facilities cannot be billed as prolonged services.

So, when billing 99215 with a 99354 or 99355 you’d need to first understand the rules associated with billing a prolonged service code along with an EM code when the EM code is based on counseling and coordination of care.

CMS outlines this in section H of the provider manual:

  1. Prolonged Services Associated with Evaluation and Management Services Based on Counseling and/or Coordination of Care (Time-Based)

When an evaluation and management service is dominated by counseling and/or coordination of care (the counseling and/or coordination of care represents more than 50% of the total time with the patient) in a face-to-face encounter between the physician or qualified NPP and the patient in the office/clinic or the floor time (in the scenario of an inpatient service), then the evaluation and management code is selected based on the typical/average time associated with the code levels. The time approximation must meet or exceed the specific CPT code billed (determined by the typical/average time associated with the evaluation and management code) and should not be “rounded” to the next higher level.

In those evaluation and management services in which the code level is selected based on time, prolonged services may only be reported with the highest code level in that family of codes as the companion code.

In other words, you have to bill the prolonged service codes with the highest code in that particular family of codes, like 99205 or 99215.

Next, you have to understand the thresholds required to select the 99205 and 99215 along with the prolonged service codes:

  • 99205 and 99354 = 90 – 134 minutes of total time
  • 99205 and 99354 and 9935 = 135 minutes or more of total time
  • 99215 and 99354 = 70-114 minutes of total time
  • 99215 and 99354 and 99355 = 115 minutes or more of total time

Now, how do you document the EM and prolonged services for CMS:

Documentation requirements from CMS:

  1. Documentation

Documentation is not required to accompany the bill for prolonged services unless the physician has been selected for medical review. Documentation is required in the medical record about the duration and content of the medically necessary evaluation and management service and prolonged services billed. The medical record must be appropriately and sufficiently documented by the physician or qualified NPP to show that the physician or qualified NPP personally furnished the direct face-to-face time with the patient specified in the CPT code definitions. The start and end times of the visit shall be documented in the medical record along with the date of service.

Finally putting it all together so we maintain compliance – I outline this specifically because CMS does not expect these codes to be used at a high frequency:

Selecting a 99215 and 99354

  • Start: 9:00 end 10:10 = 70 minutes face to face – more than 50% of which was spent in: counseling and coordinating care over the following issues: _______________ (meets requirements of rule D & H above)

Both times together equal (40 + 30) = 70 minutes.  This meets the threshold outlined above for 99215 and 99354 on the same day.

Georgia Academy Participates in Insurance Commissioners Stakeholder Meeting

GAFP President-Elect, Jeff Stone, MD pictured with Commissioner of Insurance Jim Beck

GAFP President-Elect – Jeff Stone, MD recently represented the Academy at a health industry stakeholder meeting convened by newly elected Commissioner of Insurance Jim Beck.  Over 50 representatives attended at the DOI headquarters which included the medical community and the largest health insurance companies in the State.

Commissioner Beck stated that his intention was to bring all the players together to see if there could be mutual communication to cut current administrative burdens on clinicians and hospitals.  The following areas were specifically discussed:

  1. Prompt Pay Compliance and Appeals
    • Prior Authorization Practices
    • Appeal Rejections
    • Prompt Pay Abuse
    • Accounts to Serve
    • Location of Service
    • Differences Between Certification and Pre-Pay
  2. Speed of Physician Credentialing
    • Delays in Loading
  3. Directory Updates/Inaccurate Information in Provider Directory
  4. Excessive Medical Record Requests
  5. Pharmacy Clawbacks
  6. Fraud Issues

Dr. Stone led one of the focus groups and staff from the Department took feedback on these topics.  Our intent is to continue to work with the Commissioner and his team and encourage him to vigorously tackle these issues that frustrate us as family physicians, and many times delay or deny care to our patients.